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The procedure described by CPT® Code 41005 involves the intraoral incision and drainage of an abscess, cyst, or hematoma specifically located in the superficial sublingual region, which is situated under the tongue. This procedure is typically performed when there is a need to relieve pressure and remove infectious or fluid-filled material that has accumulated in this area. The process begins with the identification of the abscess, cyst, or hematoma, followed by an incision through the mucosal tissue to access the underlying pocket of fluid or pus. Once the incision is made, the abscess pocket, cyst, or hematoma is opened to allow for drainage. During this step, any compartments that may have formed within the abscess pocket are carefully broken up to ensure complete drainage. Additionally, if there are any blood clots present within a hematoma, these are also removed to facilitate proper healing and recovery. The use of drains may be indicated depending on the extent of the drainage required. It is important to note that this code is specifically for superficial cases; for procedures involving deeper tissues or different anatomical locations, other CPT codes such as 41000 or 41006 should be utilized accordingly.
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The procedure described by CPT® Code 41005 is indicated for the following conditions:
The procedure for CPT® Code 41005 involves several key steps to ensure effective drainage of the abscess, cyst, or hematoma located in the superficial sublingual region:
After the completion of the procedure, the patient may require specific post-procedure care to ensure proper healing and recovery. This may include instructions on oral hygiene to prevent infection, monitoring for any signs of complications such as increased swelling or pain, and follow-up appointments to assess healing. The provider may also advise on dietary modifications to avoid irritation of the surgical site. It is important for the patient to adhere to all post-operative instructions to promote optimal recovery and prevent recurrence of the condition.
| Short Descr | DRAINAGE OF MOUTH LESION | Medium Descr | INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC | Long Descr | Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial | Status Code | Active Code | Global Days | 010 - Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 33 - Other OR therapeutic procedures on nose, mouth and pharynx |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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